156
JCPSLP
Volume 16, Number 3 2014
Journal of Clinical Practice in Speech-Language Pathology
Charissa Zaga
is a speech pathologist working within the acute
care setting. Charissa has a keen interest in quality and safety in
healthcare, specifically, the efficiency of the systems and
processes that underpin clinical management. She is currently
undertaking a Master of Public Health.
Joanne Sweeney
is the
manager of speech pathology at Austin Health. Joanne has a
longstanding interest in safety, quality and risk and concepts of
clinical governance as they apply to the speech pathology
profession.
Correspondence to:
Charissa Zaga
The Austin Hospital, Austin Health
145 Studley Rd, Heidelberg, Melbourne VIC 3084
phone: +61 (0)3 9496 5000
Health was reinforced to stakeholders along with the
potential associated risks for patients with incorrect meal
provision. This increased knowledge engendered improved
compliance with the steps in the process map and
highlighted the importance of accurate communication and
diet/fluid code matching.
Significant differences in the number of meals delivered
between audit 1 and audit 2 means the results of this study
need to be viewed with caution. It is unknown whether the
two interventions applied were directly effective in increasing
the overall accuracy of the meal provision system and
ultimately minimising the number of incorrect meals delivered.
A further larger audit is required to explore this further
regarding the local texture modified meal provision at HRH
and RTRC sites.
Intuitively, an additional supervisor on the plating line and
the new allocation of a supervisor to streamline meal tray
switching in the re-therm trolley following diet/fluid code
changes may increase the accuracy of meal provision.
Anecdotal feedback from food services department
staff has reported this change was positive as it enabled
increased consistency in the process and confidence that
the staff were delivering the right meal to the right patient.
In future it would also be valuable to continue to embed
elements of the National Safety and Quality Health Service
Standards (Australian Commission on Safety and Quality
in Healthcare, 2012), such as patient identification and
procedure matching, clinical governance, partnering with
consumers and clinical handover to maximise patient
safety, experience of care and minimisation of risk relating
to meal provision.
Conclusion
The meal provision system at the Austin Hospital is
complex and relies on up to seven stakeholders’ timely and
clear roles within the process to ensure accuracy and
safety. With all complex systems, stakeholder engagement
and multiple small projects targeting different aspects of the
system are necessary to effect meaningful change and
improve outcomes. Limited funding availability for large-
scale change in this area (e.g., technology software
changes, and use of online menu reporting, etc.) results in
reliance upon education and engagement with relevant staff
and increasing efficiency and accuracy within existing
resources. Reduction in the number of incorrect meals
delivered following intervention was observed. The risk of
patients receiving the incorrect meal remains at each meal
service however, making continued efforts to minimise the
risk is essential.
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